Month: July 2015

The Government is committed to delivering seven day services to make sure that patients get the same high quality, safe care on a Saturday and Sunday as they do on a week day.

1. The definition of ‘committed’ from google “the state or quality of being dedicated to a cause, activity”. This would suggest a sustained ‘dedication’ to a cause.

2. However, the NHS has seen a fall in funding year on year as % GDP – 9.7 in 2009 (inflatedly high due to the economic recession), to 9.1 in 2013. [1] The absolute spending per capita has also fallen; from a high of $3916 per head of population in 2007 to $3598 in 2013. This is the lowest bar Italy of the G7 countries (Japan, Canada, US, Italy, France, Germany, and the UK) as well as lower than most of Western Europe and New Zealand.

3. From the data, see below, into ‘safe’ weekend care, this mostly applies to emergency care – therefore ‘safe’ should focus on funding A&E and GP. Dozens of A&Es have been downgraded or closed [3] and 169 GP practices are either contemplating or planning closure in 2014/15 [4].

Many people do not realise that if you are admitted to hospital on a weekend, you have a 16% greater chance of dying.

1. The reason they don’t realise this is because it’s not true. The narrative from the government is : “if are you admitted at the weekend, there is a 16% chance that you wil die in hospital, and this is due to a lack of care from professional who would otherwise be there if it wasn’t a pesky Sunday”. The government also hasn’t officially attributed this figure to any research: however the figure is lifted from here.

2. Here are two analyses of said paper- juniordoctorblog and abrainiablog. The actual narrative is more complex, but to summarise it probably goes “Research shows emergency patients admitted on a Sunday are 16% more likely to die in the next thirty days as patients on a Wednesday, a third within three days, during the week, and a third after discharge, after weeks in hospital. Additionally, patients, in hospital, are 8% less likely to die on a Sunday than a Wednesday. This probably reflects the fact patients have to be more unwell to present to A&E on a Sunday than a Wednesday, but it is very unclear the reason why.” What is very clear however is that the bump in mortality applies primarily to emergency admissions.

The Government wants to change this

1. Which will be extremely hard to do if you fail to understand what ‘this’ actually represents.

so that everyone can be confident that they will receive the same level of care whatever day of the week they are admitted to an NHS hospital.

2. But we know, to improve safety, we must improve emergency admissions. That is in no way the same as ‘the same level of care’ which encompasses the whole weekday non-emergency NHS activity. If you have a resource finite environment you prioritise to increase the best outcome- limiting mortality over morbidity over inconvenience. This is a fundamental principle of healthcare.

3. The ‘same level of care‘ targeted in the contracts is, by definition, non-emergency care. Firstly, the data linked to increased 16% in deaths in weekend admissions is entirely emergency admissions, which are already covered. Secondly, a recent FOI request found, so far, of 4101 consultants NONE have opted out. (Explicit thanks to Kiara Vincent who filed all of these requests [7]). Here is a table.

UPDATED 28/7/15: I will just reiterate that. Not a single consultant has been found to be opting out of non-emergency care. NOT ONE. NADA. NIL. NO ONE. The previous single Pennine doctor, found to be opting out initially, turns out had opted out of the European Working Time Directive to help with ‘service demands and provision’. This means they worked longer than a 48 hour week, i.e extra hours for the benefit of the hospital. [16] (Thanks to Dr Hugh Harvey for the follow-up excellent piece of FOI).

5. ‘Same level of care‘ does not mean ‘consultant presence’- it should mean the same doctors, porters, nurses, OT, physiotherapists, radiographers, MRI and CT access, biochemistry and microbiology access. The system can’t afford this on current funding- regardless how much doctors are forced to work for how much that will not change.

NHS consultants already provide an outstanding service and show great dedication to ensuring patients get the best outcomes.

1) Yes they do. In fact here are the WHO outcomes for the NHS compared with the rest of the world. Here they are in 2010 through to 2013. No change- despite the levelled ‘failings’ of the NHS the actual numbers are not changing.

But the Government has a duty to make sure the system is set up in a way which makes it as easy as possible for hospitals to organise their resources to maximise patient safety across every day of the week.

1) It doesn’t technically have a duty to provide a comprehensive NHS anymore [8] as of the 2012 Health and Care Social Act.

2) Organisation of resource- already the system is stretched, during the week or weekend. Admissions are increasing [9] from 11.9 million in 1998 to 18.2 million in 2013 and many hospitals are in debt due to PFI [10] deals that no one has offered to renegotiate. What would increase patient safety is redeployment of resources to increase ancillary staff, to fund A&E and staff it, and to the renegotiation of PFI deals to end their crippling interest**.

3) Additionally under new immigration rules [11] will mean the culling of about 3500 NHS nurses, which has not only financial implications but the loss of experience from the utter bedrock of the NHS will be catastrophic- so there are much bigger problems than seven-day non-emergency convenient services.

To understand more about the possible issues for staff contracts,

1. Read ‘to make a political show of backing our own aggressive undermining policies toward the medical profession’.

last year the government asked the independent pay review bodies for NHS staff – The Review Body on Doctors’ and Dentists’ Remuneration (DDRB) and the NHS Pay Review Body (NHSPRB) for their observations and recommendations about how the reform of employment contracts could help support the delivery of seven day services in England.

The reports were published this month. They identified that a major barrier to seven day services is a decade old contractual right in the consultants’ contract negotiated by their union representatives in 2003 that allows senior doctors to refuse to work non-emergency work in the evenings, at nights and at weekends.

1) So here the Government [UPDATED]: MUST HAVE LOST THEIR MINDS if that is a ‘major barrier’ to seven day services. I.E the evidence is clear, not a single consultant so far has opted out, therefore this is utterly malicious rubbish.

What constitutes non-emergency care? For example: Hip replacement, dermatology opinion, shoulder physiotherapy. Do you want to get an eye test at 2am? Probably not. But you might want to at 9am on Saturday? So would I- except thats a cost to pay for convenience, not safety. ***

No junior doctor, nurse or other clinical group has any such right.

1. Except they do- junior doctors would not be expected to see non-emergency patients out of hours ‘on call’- they would be properly sent to GPs or ambulatory care units. What goes on in hospitals depends how you define ‘non-emergency’. If you take emergency to mean new admissions, unwell patients and complex patients requiring daily review these are standard on call duties. But, non-emergency work over the weekend, for example doing blood tests that take weeks to get a result (e.g genetic sequencing) or seeing a patient with acne, pull time away from emergency patients unnecessarily. We can’t ‘opt-out’, but that doesn’t mean that we are providing a 24-7 non-emergency service and only consultants are missing – this is a gross misrepresentation. And additionally no consultant IS opting out.

Other senior public sector professionals who work in services required to keep the public safe, such as police officers, firemen and prison governors, do not have this opt out either.

1. Following along- suddenly non-emergency opt out= safety. If there is any non-emergency police or fire work that our colleagues are doing at weekends and nights, please let us know.

Whilst the vast majority of consultants work tirelessly for their patients,

1. Correction- they all do.

the opt out allows individuals to charge employers hugely expensive payments which are much higher than national contract rates (up to £200 an hour).

2. UPDATED: The evidence is clear, whoever wrote this is actually referring to agency doctors covering staff shortages NOT any single doctor reaping the rewards of imaginary opt-outs. (Which, let me labour the point, DOES NOT EXIST).

The average earnings for a hospital consultant are already in the top 2% in the country at £118,000, and these inflated payments can make it difficult for hospitals to provide the weekend cover they know patients need.

1. Average UK earnings for consultants- this is not clear, the top salary after 19 years of being in post is £101,451 – I struggle to find how the average is 118K. Here is the pay scale: [12] Who else is in the top 2%? [13] In a list that includes brokers, chief executives, financial managers, sales directors and PR directors only two other professions are comparable: pilots and air traffic controllers. No job in that list requires AT LEAST 14 years of training (6 years of medical school and 8-10 years of postgraduate training) and holds the responsibility for life and death. And don’t forget the cost of indemnity to handle that responsibility.

2. Inflated payments that make it difficult; what also makes hospital finances difficult are PFI deals, and locum costs for overstretched departments like A&E when other hospitals have closed.

3. We, as a profession, know the patients need ‘weekend cover’ for emergencies– which is already in place. This should be better funded.The report endorsed the removal of the opt out, as well as broadly supporting other changes to the consultant contract that would ensure the right level of cover is available every day of the week; not just Monday to Friday.

1. The DDRB has rubber stamped the government and is not independant at all. It also recommended a pay rise- which the government completely ignored. ****

Under the new plans, doctors will still continue to receive a significantly higher rate for working unsocial hours

and there will be a contractual limit (not an expectation) of working a maximum of 13 weekends a year.

1. The redefinition will actually mean an effective pay cut, possibly in the realms of many thousands of pounds. [14]

By the end of the Parliament, the Government hopes that the majority of consultants, in line with existing practice for nurses, midwives and junior doctors, will be on reformed contracts,

1. As above, this will mean a pay cut and longer hours and no benefit to patients other than convenience, but likely an overall much worse service, in the context of an already besieged emergency system.

working across seven days, to deliver a better service to patients.

2. Note now the aim is service and not safety.

Hospitals like Salford Royal and Northumbria that have instituted seven day services have already seen improvements in patient care and staff morale.

1. These improvements [15] are all in the emergency areas and acute wards, no non-emergency work at all.

These new plans will mean that doctors working in some of the toughest areas in the NHS, such as A&E and obstetrics, will at last be properly rewarded and there will be faster pay progression for all consultants early on in their career.

Under the new proposals, the highest performing consultants could be able to receive up to £30,000 a year in bonus payments, on top of their base salary. Of course, improving weekend care requires more than just ensuring greater consultant presence.

1) Really? First time this is mentioned.

That’s why the government is also addressing issues such as access to weekend diagnostic services, provision of out of hospital care to facilitate weekend discharges, and adequate staffing cover amongst other clinical groups,.

2) Really, where?

But NHS leaders and the independent pay review bodies are clear that increasing the presence of senior clinical decision makers at weekends is vital, and that the consultant opt out remains a barrier to organising broader support services and staff rotas.

3) [UPDATED] 28/7/15: I’ll just reiterate: WHAT BARRIER? THERE ARE NO OPT OUTS. IT LITERALLY TOOK ABOUT 3 PEOPLE 2 HOURS TO FIND THIS OUT. MAYBE SPEND A BIT LONGER ON NATIONAL HEALTH POLICY THAN A TEATIME. *****

The Government feels it is under an obligation to the public to do all it can to make NHS care at the weekend as safe as during the week through the delivery of seven day services this Parliament and that is what it will continue to do.

1) And back to ‘safety’.

PHEW.

This is an infogram to summarise the governments reasoning for seven day care.

While the real thinking is;

1) How can we make the NHS more into a ‘consumer’ friendly service, despite the fact that we know the funding will not cover such a change, and simultaneously demoralise doctors and staff to the point that both patients and staff will look to ‘private’ reform as a crisis solution.

It doesn’t get a lot of media coverage but here is some interesting information on the Health Secretary, the Right Honourable Jeremy Hunt.

1) He co-authored a book called ‘Direct Democracy’ which explicitly idealises the dismantling of the NHS and how to do it

2) In 2012 he was stepped down from the position of Culture secretary following accusations of corruption over the BSkyB deal- putting private interests first over public benefit.

3) He has no medical or scientific qualifications whatsoever- he has a 1st class degree in Philosophy, Politics and Economics from Oxford.

4) His background is business, but he did try to make it as English Language Teacher. I wish he’d stuck with it.

5) It is a instant dismissal offence in the NHS to break patient confidentiality. A picture from Mr Hunts visit to an NHS hospital showed the names of several patients for surgery. The DoH found the picture, shared to 70,000 people, was an ‘innocent mistake’. Still no one has apologised to the named patients on the list, telling the whole world about their medical histories without their consent.

**Yes, most of these PFIs came from the last Labour government. There are few heroes in this story.

***Perhaps a more reasonable solution would be to create a statutory medical appointment payment- this would pay a small fee for missed work to companies where patients are away attending non-urgent appointments.

****The DDRB is also destroying the junior doctor contract- altering it to make unsociable hours extend to 7am-10pm at Monday to Saturday. 9pm on a Saturday for your in-growing toenail removal?

*****I am a little sad I had to remove the phrase “Nuclear Powered Super Doctor”, so I’ve archived it here for posterity.

Patients admitted on a Sunday were more likely to die over the next thirty days than a similar cohort of admissions on Wednesday- the ratio was 1.16 and the result significant, suggesting a true result of increased deaths by 16%

94% of these ‘admissions’ were emergencies

34% of deaths occurred within three days of admission

You are actually less likely to die if you are IN hospital on the weekend – the Sunday to Wednesday ratio here is 0.92, or 8% LESS likely. As the authors also conclude, this likely reflects the fact that high-risk, non-urgent procedures are performed during the week.

For elective (non-emergency) admissions, the ratio was 1.62 for Sunday to Wednesday, suggesting a 62% increased chance of death. This, as the authors conclude, is likely biased by the fact that high-risk elective patients are brought in early in general for exactly this reason, therefore this is unlikely to be significant.

Of 10 conditions specifically looked at, only 7 were found to show the same increased risk: sepsis, acute renal failure, cancer of the bronchus or lung, myocardial infarction, acute stroke, and congestive heart failure.

The authors also conclude: “7-day access to ALL ASPECTS of care” could improve such figures, but further ‘economic evaluation’ is required to ensure efficiency with ‘scant resources’ [para]

A further third of patients in this study died after discharge

So to summarise, you are 16% more likely to die, over the next thirty days, if you come into hospital on a Sunday- 30% will die within three days (Mon-Tues), and a further 30% will die after discharge. This only applies to emergency admissions, and a list of medical emergency conditions.

One major criticism, published by the authors themselves, is the fact that any conclusion completely ignores the reason for admission and the route of admission- there are no routine GP services on the weekend, and the impetus to admit on a weekend has to be higher than the week when most people would hold out for the GP unless they were very unwell. This immediately selects out a group of sicker patients than might routinely come in on a Wednesday.

Now we will play a game called ‘Jeremy Hunt spectacles’.

I look at this paper with ‘Jeremy Hunt Spectacles’ and read the abstract ‘admissions on a Sunday…16% more likely to die vs a wednesday’ and then completely stop reading and decide that a) 15% is a rounder, more soundbite-friendly number b) this must be the consultants fault c) I should go and tell them, loudly and with contract renegotiations for the entire consultant body. Or more realistically d) this would be excellent to further my agenda of privatising the NHS (despite that later in the paper the private US system shows the exact same pattern).

Now I take off the spectacles and look again.

The paper shows that patients admitted on Sunday, overwhelmingly emergencies, do worse during the entire course of their illness episode than those on Wednesday, but they deteriorate during the next three days (30%) over the weekdays, or even after discharge (34%) ie all on weekdays or even weeks of admission. Of the commonest conditions they are all medical emergencies.

Therefore, the suggestion is there is a decreased level of care on a Sunday admission, assuming that the patients are not genuinely sicker on average as suggested above, and that exarcebates or worsens an illness episode greater than a Wednesday admission. This extra initial insult, in 16% of patients, is not survivable. The ward patients however, appear generally unaffected weekend or weekday.

So what do the Wednesday patients get, that the Sunday patients don’t get? Consultants? In every hospital I have worked in that is simply not the case. Think about the admission process; in A&E there is always a consultant, on a 7-day 24-hour basis. Most have 3 or 4 at a time. For this set of patients they go to acute medicine where the standard is a daily consultant ward round, some twice or even thrice daily. So that is not going to help Mrs Sunday.*

What is not there? Only limited access to their GP, which in turn increases the workload in A&E, limited radiographer and lab techs, echocardiogram technicians, reduced pharmacy cover, and the hordes of office hours staff – secretaries for vital notes from other hospitals, semi-urgent referrals to other teams, the list goes on. In other words the missing £20 billion from the £100 billion budget that has already been cut away.

So, looking at the same problem, where emergency admissions are the chief cause of the 15% bump in mortality, what is the rational response? To increase funding and GP resources, to staff and fund A&E and acute medicine and other acute specialties and to support community services.

Has this been done? No.

Instead- GPs have been pushed on to duties they didn’t want in the form of the wholly rejected Health and Social Care Act, at a conservative estimated cost of £1.5 billion [2], and instead of funding and supporting emergency admissions A&Es have been closed and the specialty chronically under recruited, despite warnings. In other words, the areas designed to prevent this exact problem, identified in 2010, have been systematically underfunded and cut by the current Government for the last 5 years.

So, is an attack on consultant contracts, who are already working weekends and nights in vital areas, going to save 6100 lives? Clearly not. The system needs to extend through the multidisciplinary teams and out of the hospital and into GP land and social care- this needs to focus on emergency admissions. So while there is a neat political capital in claiming 7-day NHS services is good for patients- it’s an appeal to convenience, not safety, and no regard to resource. If you want all the staff and equipment and resources available 24 hours a day, you will need another two 8 hour shift equivalents- another 300,000 doctors, 800,000 nurses, 310,000 multi-discplinary team members. If you have a spare annual £200 billion, this would be a good time to speak up.

And in the meantime Lord Prior, the parliamentary under-secretary of state for NHS productivity, quietly announces an inquiry into private charges and insurance to fund the NHS. I.e to move the system from tax-funded to full charge-based private healthcare. [3]

So, Jeremy Hunt, is not stupid. He isn’t ignorant- he is inflammatory. He is not incompetent he is corrupt. There is an agenda here far wider than doctor-bashing.

While myself and my colleagues post #ImInWorkJeremy tweets in solidarity against changes to our contract, the political conversation is focused on us, while behind the scenes one of the greatest healthcare systems in the world is quietly dismantled by politicians and Lords with no democratic mandate to do so.

All doctors would like a 7-day NHS- we would like all the resources we have at the weekdays to do the best for our patients. Just come and witness the frustrated arguments with midnight radiographers and rushing to on call pharmacy at 11.55 am on a Saturday. But you learn to prioritise as well- that’s why you want to be the patient kept waiting, because the patient we are running to is usually the one in a hurry to die.

Perhaps Jeremy Hunt needs a lesson on prioritisation. Or perhaps he, Lord Prior and the rest of the Conservative government are not prioritising patients at all.

*In fact this is exactly the changes made at Northumbria hospital, mentioned in the same breath in the same speech by Mr Hunt as an example 7-day service, to increase acute medicine and A&E Services, NOT the entire hospital.

**. And for what’s it’s worth: this is day 6 of my 12 day shift. Lazy old me.